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Prenatal Intake Form
Section 1: Demographics
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Indicates required field
Name:
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First
Last
Prefers to be called:
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Birth date (mm/dd/yyyy):
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Height:
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Weight:
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Age:
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Gender
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Male
Female
Home Address:
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Line 1
Line 2
City
State
Zip Code
Country
Home Phone Number
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Cell Phone Number:
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Email Address:
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Preferred Method of Contact:
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Home Phone
Cell Phone
E-mail
Marital Status
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Single
Married
Divorced
Widowed
Other
Spouse's Name:
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Number of Children:
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Children's Names and Ages:
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Occupation/Job Description:
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Emergency Contact Name:
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Emergency Contact Phone
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Emergency Contact Relationship:
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How were you referred to our office?
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Section 2: Your Current Pregnancy
Due Date/Week:
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Current Weight:
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Pre-Pregnancy Weight:
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Height:
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Childbirth Caregiver(s):
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OB/GYN
Doula
Midwife
Other
Caregiver's Name(s):
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Caregiver's Phone Number:
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Last Visit to Caregiver (mm/dd/yyyy)
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I plan on giving birth at:
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Hospital
Birth Center
Home
Other
Name of Hospital or Birth Center
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Any traumas during this pregnancy?
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Yes
No
If yes, please describe:
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Any hospitalizations during this pregnancy?
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Yes
No
If yes, please describe:
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Please list any medications or supplements you have been taking during this pregnancy:
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Please describe any fertility treatments undergone:
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Section 3: Reasons for Seeking Care
I am seeking care at this office
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Because of pain or symptoms during my pregnancy (Please complete section 3A)
General wellness care during my pregnancy
To help facilitate a more natural birth experience
Breech or other malposition
Other
Section 3A: Pain and/or Symptoms
Please complete this section if you are experiencing any pain or symptoms during this pregnancy.
Please describe your pain or symptoms:
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When did you first begin to notice your symptoms?
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Where are you feeling the symptoms?
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Quality of Symtoms: (What does it feel like?)
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Dull
Achy
Numbness
Tingling
Stiffness
Sharp
Cramping
Nagging
Burning
Shooting
Throbbing
Stabbing
Other
Prior Interventions: (What have you done to try and relieve the symptoms?)
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Have you missed any work due to your symptoms?
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Yes
No
How have your symptoms affected your daily activities or routines?
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Section 4: Previous Pregnancies/Births
Number of previous pregnancies:
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Number of previous births:
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Your previous births were at:
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A Hospital
Home
A Birth Center
Other
Medications used in prior births:
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None
Ptocin
Epidural
Other
Interventions used in prior births:
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Breaking of water
Vacuum
Foreceps
Episiotomy
C-Section
Other
How long was your previous labor?
Total Time:
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Time you pushed:
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Did you have chiropractic care during your previous pregnancies?
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Yes
No
Section 5: Complete only when you are past 32 weeks:
Position of baby:
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Head down
Posterior
Breech or malpositioned
Position confirmed by:
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Palpation
Ultrasound
Date confirmed:
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Section 6: General Health History
Please select any past or current conditions that apply:
A. Musculoskeletal:
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Osteoporosis
Knee Injuries
Arthritis
Gout
Foot/Ankle Pain
Scoliosis
Shoulder Problems
Hip Disorders
Neck Pain
Elbow/Wrist Pain
Back Problems
TMJ Issues
D. Respiratory:
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Asthma
Shortness of Breath
Sleep Apnea
Pneumonia
Hay Fever
Emphysema
G. General:
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Appetite Changes
Low Libido
Cancer
Eating Disorder
Concussion
B. Neurological:
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Anxiety
Dizziness
ADD/ADHD
Depression
Seizures
Confusion
Headache
Numbness
Loss of Balance
G. Skin:
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Skin Cancer
Psoriasis
Eczema
Hair Loss
Rash
H. Reproductive:
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Difficulty Conceiving
Breast Tenderness
Irregular Periods
Breast Implants
Painful Periods
PMS Issues
C. Cardiovascular:
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High Blood Pressure
Low Blood Pressure
Irregular Heart Beat
High Cholesterol
Excessive Bruising
Pacemaker
Angina
Poor Circulation
Stroke
H. Endocrine:
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Thyroid Issues
Immune Disorder
Hot Flashes
Frequent Infection
Low Energy
Swollen Glands
D. Digestive:
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Food Sensitivities
Digestion Problems
Gallbladder Disease
IBS
Ulcer
Constipation
Diarrhea
Heartburn
F. Urinary:
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Kidney Stones
Frequent Urination
Bedwetting
Please list any surgeries or past surgical interventions:
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Past Injuries - Do you have a history of any of the following?
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Fractured or broken bone
Spine or nervous system disorder
Being knocked unconscious
Injury in an accident
Bad fall or injury
Other
None of the above
Please list any medications you are taking with reason for use (prescription and over the counter):
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Please list any nutritional supplements/vitamins you are currently taking:
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Please check the treatments you have received in the past, or are receiving currently:
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Acupuncture
Chemotherapy
Chiropractic
Dialysis
Herbal Remedies
Homeopathy
Massage Therapy
Physical Therapy
Other
Section 7: Personal Health Habits & Lifestyle
How often do you use the following:
Alcohol
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Everyday
Once per week
2 to 3 times per week
Once per month
Less than once per month
Never
Coffee
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Everyday
Once per week
2 to 3 times per week
Once per month
Less than once per month
Never
Energy Products
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Everyday
Once per week
2 to 3 times per week
Once per month
Less than once per month
Never
Soft Drinks
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Everyday
Once per week
2 to 3 times per week
Once per month
Less than once per month
Never
Drugs
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Everyday
Once per week
2 to 3 times per week
Once per month
Less than once per month
Never
Exercise
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Everyday
Once per week
2 to 3 times per week
Once per month
Less than once per month
Never
Please rate your stress level on a scale from 0-10 (0=no stress and 10=extremely high stress):
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Is there any additional information you would like us to know about you or our pregnancy?
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The Webster Technique Defined
The International Chiropractic Pediatric Association defines the Webster Technique as a specific chiropractic analysis and adjustment that reduces interference to the nervous system and balances the pelvic muscles and ligaments, which in turn removes torsion to the uterus, reducing the potential for intra-uterine constraint and allows the baby to get into the best possible position for birth.
Section 8: Acknowledgements
To set clear expectations, improve communication and help you get the best results, please read each statement and initial your agreement.
I instruct the chiropractor to deliver the care that, in her professional judgment, can best help me in my restoration of my health. I also understand that the chiropractic care offered in this practice is based on the best available evidence and designed to reduce or correct vertebral subluxation. Chiropractic is a separate and distinct healing art from medicine, and does not proclaim to cure any named disease or entity.
Initials:
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I may request a copy of the Privacy Policy and understand it describes how my personal health information is protected.
Initials:
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I grant permission to be called to confirm or reschedule an appointment and to be sent occasional cards, letters, emails or health information to me as an extension of my care in this office.
Initials
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I acknowledge that I am responsible for the timely payment of any and all services I receive.
Initials:
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To the best of my ability, the information I have supplied is complete and truthful. I have not misrepresented the presence, severity or cause of my health concern or health issues.
Initials
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Submit
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